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Post-Operative Care of Congenital Heart Disease Patients

Post-Operative Care of Congenital Heart Disease Patients. A brief pediatrics perspective. Electrolytes. Severe electrolyte abnormalities Cause: Pump solutions, saline solutions, fluid shifts. Most important are those with effects on heart Potassium (arrhythmogenic)

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Post-Operative Care of Congenital Heart Disease Patients

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  1. Post-Operative Care of Congenital Heart Disease Patients A brief pediatrics perspective

  2. Electrolytes • Severe electrolyte abnormalities • Cause: Pump solutions, saline solutions, fluid shifts. • Most important are those with effects on heart • Potassium (arrhythmogenic) • Calcium (affects contractility and arrhythmias) • Magnesium (same as Ca) • Also, but less important • Sodium and phosphate

  3. Glucose • Hyperglycemia (outside of neonatal period) • Causes: • Stress response • Endogenous steroids • Epinephrine • Steroids given for bypass • Tx: Incr sedation & pain control

  4. Renal Effects • All due to decr MAP and non-pulsatile flow. • Release of • Angiotensin • Causes HTN • ADH • Causes retention of free water leading to hyponatremia • Catecholamines • Causes HTN and faster heart rate. • Tx: Antihypertensives, Lasix.

  5. Renal Effects, cont. • Acute Renal Insufficiency (incidence 8%) • Oliguria • Incr creatinine • Fluid retention • Tx: • MUF • Lasix

  6. Pulmonary Effects • Causes • Leukocyte & complement activation • Surfactant loss • Results: • Capillary leak… pulmonary edema. • Atelectasis • Tx: ventilation with increased PEEP

  7. Pulmonary, cont. • Pulmonary Hypertension • Constriction of pulm vascular bed • Leads to poor oxygenation • Caused by acidosis & high CO2 • Tx: Hyperventilation. • Reperfusion injury • Unique to Pulmonary Stenosis • Very common in pediatric CHD (esp. ToF) • Related to procedure itself, not bypass. • Presents as pulmonary edema • Tx: Diuretics.

  8. Coagulopathy • Causes: • Activation of clotting factors in tubing • Real clotting to stop surgical bleeding • Hemodilution • Heparin in pump • Tx: • FFP • Protamine

  9. Hemodynamic Effects • Tissue ischemia, capillary sludging due to low MAP and non-pulsatile flow. • Leads to Lactic Acidosis. • May exacerbate electrolyte disturbances • Potassium driven into cells with acidosis • Worse with longer bypass duration. • Tx: shorten bypass time, bicarb, vent.

  10. Hemodynamics, cont. • Hemodilution from pump priming solutions, iv fluids & renal insufficiency. • Result worsens HCT than just surgical blood loss. • Tx: • Modified Ultrafiltration (MUF) • Lasix • PRBC

  11. Hemodynamics, cont. • Myocardial dysfunction • Usually Right Ventricle in children (unlike adults) • Increased CVP, decreased Bp and UOP • Tx: • Dopamine • Epinephrine • Dobutamine

  12. Hemodynamics, Cont. • Capillary leak… diffuse edema • Caused by inflammatory mediators activated against tubing of bypass. • Worse in children than adults • Length of tubing is longer in relation to the length of the child’s vascular system. • Tx: Lasix, limiting of IV fluids.

  13. Conclusions • Overall the pathophysiology of bypass is similar to Systemic Inflammatory Response Syndrome seen in patients with sepsis. • Similar derangements in coags, capillary permeability and tissue ischemia occur in both. • Bottom line: minimize the pump time!

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